Cases/Continuity and Quality of Care, Safety and Prescribing

Calling A Patient After A Pharmacist Flagged Your Methotrexate Prescribing Error — Free SCA Practice Case

Calling a patient after a pharmacist flagged your methotrexate prescribing error

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Bernice Pomfret

Age

64 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. You are calling the patient.

Reason for Encounter

"Pharmacist phoned the practice this morning about a methotrexate prescription issued yesterday, collected yesterday afternoon."

Medical Records

●PMH: Seropositive rheumatoid arthritis, 9 years, under rheumatology. Hypertension.
●Medications: Methotrexate 2.5 mg tablets, four once weekly (previous repeat); folic acid 5 mg once weekly; amlodipine 5 mg daily.
●Allergies: NKDA.
●Social: Part time building society customer adviser.

Recent Notes

●Issued yesterday: methotrexate 2.5 mg tablets, four tablets once daily.
●Bloods 6 weeks ago: Hb 128, WCC 5.8, neutrophils 3.4, platelets 251, ALT 24, albumin 41, creatinine 71, eGFR 82.

Patient Script

For the friend playing the patient role

Character Overview: You are Bernice Pomfret, a 64 year old part time customer adviser at a building society branch, off work today. You live with your husband Geoff, a retired joiner, who has gone to play bowls and will be back in about half an hour. Your daughter Colette, an optician's dispenser, lives fifteen minutes away. You have had rheumatoid arthritis for nine years and have taken methotrexate for six of them, four tablets once a week on the same evening, with folic acid the next morning. Your hands have been settled for a long time and you are proud of keeping on top of it. You are careful, polite and a bit anxious, the sort of person who reads every label and does as she is told. You have been registered at this surgery for many years and trust the doctors. You are not expecting this call. You assume it is about your blood test or a letter. Your voice is warm and a little formal. It wobbles when you realise something is wrong, and you may go quiet or tearful when you are told what has happened.

Opening Sentence: "Hello, Bernice Pomfret speaking. Oh, hello doctor. I wasn't expecting a call. Is it about my blood test?"

Identity and Privacy

●If asked to confirm who you are, you give your full name and your address when asked. You are on your own in the house and free to talk. The house phone is next to you. Your mobile is in your bag.

History if Asked (Data Gathering Phase)

●The new prescription: "Geoff collected it from the chemist yesterday afternoon. The label says four tablets once a day. It's different to my old box, which says once a week. I did wonder. I thought perhaps the rheumatology people had put the dose up and the surgery had sorted it. I didn't like to ring up and make a fuss."
●What you have taken today (answer exactly, and only after you have been asked what you have taken from the new box): "I took four with my breakfast this morning, about eight o'clock, because that's what the label said. Then at about half past twelve I took another four."
●Why the second lot (if asked why): "I'd been on the phone with my sister and I got flustered. I couldn't remember whether I'd taken them, so I took them again. I feel so stupid. I should have checked the pill box."
●Nothing since: "No, I haven't taken any more. That's all eight. I haven't had my folic acid either. That's for the day after."
●Your usual routine: "Four tablets, the 2.5 ones, once a week on the same evening, and a folic acid the next morning. Six years now. My last proper dose was five days ago."
●Other methotrexate at home: "Yes, there's my old box in the kitchen cupboard with about half left, and the new box on the shelf by the kettle."
●How you feel now: "A bit queasy since about an hour after the lunchtime ones. Not sick, no. No diarrhoea. My mouth is fine, no sores. No sore throat, no temperature, though I haven't taken it. No bruising, no cough and I'm not short of breath. I'm a bit tired, but that's nothing new."
●Passing urine and drinking: "Normal. I've had two cups of tea and some water."
●Other medicines and interactions: "Amlodipine for blood pressure, one a day. I took two ibuprofen last night for a headache and none today. No antibiotics. Nothing from the chemist apart from that, and no herbal things."
●Alcohol: "A glass of wine on a Friday and Saturday. None this week."
●Other prescriptions yesterday: "Just the methotrexate and my amlodipine. The amlodipine was fine."
●Kidneys and other health: "My kidneys have always been fine, they check every time. No liver trouble. I had hay fever when I was younger and that's it."
●Monitoring and rheumatology: "Blood tests every three months at the surgery. The last was about six weeks ago and I was told they were fine. I see the rheumatology nurse every six months. She told me methotrexate is once a week and never more."
●Allergies: "None."
●Who is with you and getting about: "I'm on my own until Geoff gets back. Colette could come in fifteen minutes if I rang her. I can drive, but I don't feel I should now."

Ideas, Concerns, Expectations

Gating note: Bernice does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks has happened, what worries her, or what she hopes for, or after the doctor has told her about the error.

●Ideas: She believed the daily dose was a deliberate increase, and now believes she has done something silly and taken too much herself. "I thought they'd put it up. Is this my fault, for taking the second lot?"
●Concerns: She is frightened it is dangerous and fears she could die or end up in hospital for weeks. She is also worried about her arthritis flaring if the methotrexate is stopped, and about how Geoff will react. "Is it dangerous? Could I die from this? And Geoff will worry himself sick."
●Expectations: She wants an honest explanation of what went wrong and a plan to put it right. She wants to be sure someone will check she is all right and she hopes it will not happen to anyone else. "I'd like to know what happened, and I'd like somebody to look after me today."

Social History and Lifestyle Impact

●Home and family: Lives with Geoff in a two storey house. Colette and her two children live fifteen minutes away. Bernice sees them most weekends.
●Work: Three days a week as a customer adviser at a building society branch. She is off today. She takes sick leave very rarely and would hate to let the branch down.
●Smoking and alcohol: Never smoked. Alcohol as above.
●Dog: She has a spaniel who needs letting out. Geoff or Colette could do it.
●Availability: She can go to hospital today if asked. She is reluctant but not unwilling and will go if given a clear reason. She wants to know how long she will be.

Responses to Management (The Negotiation Phase)

●
If the doctor tells her about the error:
- ●Reaction: Stunned silence, then a shaky voice. "Oh. So it wasn't meant to say daily? Oh dear." She wants it stated plainly. If the apology is warm and personal she says, "Thank you for telling me. I did think it was odd." If the doctor is vague, hedges or blames the system or the chemist, she says: "I don't understand. Whose mistake was it?"
●
If the doctor says she needs to go to hospital today:
- ●Reaction: If the doctor says they will first take poisons or specialist advice by phone and call her back: "Should I wait here for your call?" She then does whatever is arranged, including going in. If told straight away that she needs to be seen in hospital: Frightened and reluctant. "Hospital? Can't I just stop the tablets and see how I go? I feel nearly all right." If told that it needs checking today, that blood tests are needed and that there is an antidote which works best the sooner it is given: "Then I'll go. Should I call an ambulance?" If told Geoff or Colette can take her and an ambulance is only for if she gets worse: "All right. I'll ring Colette now."
●
If the doctor asks what she should do about the tablets and her folic acid:
- ●Reaction: Practical. "Which box shall I take? Do I still take my folic acid tomorrow?" She accepts instructions to stop all methotrexate, put both boxes aside and take them with her. If told to wait for the hospital's advice about folic acid: "Right, I'll take them and the folic acid in my bag."
●
If the doctor explains how it happened and what will be done:
- ●Reaction: Wants honesty. "How did this happen? Will you get in trouble? Is the chemist going to be told off?" If told the mistake was the doctor's own and it will be reported and looked at so it cannot happen again: "Thank you for being straight with me. I'd like to hear what comes of it." If told she can make a complaint: "I'm not looking to complain. I just want to be right." She would like a phone call later to check she got there.
●
If the doctor discusses her arthritis and future methotrexate:
- ●Reaction: Anxious. "Will I get a flare? Will I be able to go back on it?" If told the hospital and the rheumatology team will decide when and how to restart and that a short break is expected: "I can manage a few days. My hands are good at the moment."
●
If the doctor gives safety netting and a plan:
- ●Reaction: Wants specifics. "What should I look out for? How long afterwards?" If told something vague like "tell us if you feel unwell", she says: "Unwell how? What would worry you?" She repeats back specific warning signs and names who to ring when they are given.

If Asked: Associated Symptoms

Gating note: Bernice answers only when asked. All are negative unless stated.

●If asked about vomiting or diarrhoea: "No. Just a bit queasy, as I said."
●If asked about mouth ulcers or sore throat: "No. Nothing."
●If asked about fever, shivers or a cough: "No. I feel quite well really."
●If asked about bruising, bleeding or black stools: "No, nothing like that."
●If asked about a rash: "No."
●If asked about breathlessness or chest pain: "No."
●If asked about pain in the tummy: "No, just the queasy feeling."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Bernice Pomfret, 64, takes methotrexate for rheumatoid arthritis. A prescription issued yesterday by the candidate said four tablets once daily instead of once weekly. She has taken eight tablets today in two sittings, which is twice her normal weekly dose in one day, and she is mildly queasy. The station tests three things at once: immediate patient safety, an honest and personal disclosure, and the reporting and learning that follow.
●The model plan. Confirm who you are speaking to. Warn her, then tell her plainly that the prescription was your error and apologise. Establish exactly what she has taken and when, and screen for early toxicity. Tell her to take no more methotrexate from either box. Make sure she is assessed today, with someone else driving, taking both boxes, and take specialist advice and give a clear handover. Correct the prescription and repeat template and speak to the pharmacy. Tell rheumatology. Record and report the event. Phone her later and give specific safety netting.
●Acceptable alternatives: telephoning the National Poisons Information Service (through TOXBASE, which needs a professional login) and the on call rheumatology or medical team first, with her waiting for the call, and then following their advice on where and when she has blood tests and whether folinic acid is given; arranging an ambulance if she is unwell or has nobody to take her; attending the emergency department or the acute medical or ambulatory unit, whichever local pathway the hospital advises. All are fine so long as a team able to decide on tests and an antidote advises or assesses her today and the plan is not left to symptoms appearing.

Why This Is Urgent

●Methotrexate for autoimmune disease is meant to be taken once a week. Taken more often it accumulates and can cause bone marrow suppression, mouth and gut ulceration, liver and kidney injury and, in the worst cases, sepsis and death. The MHRA Drug Safety Update (September 2020) reviewed fatal and serious cases of daily instead of weekly dosing and set out advice for prescribers and dispensers.
●Her single day total is 20 mg against a usual 10 mg. Harm is less likely after one extra dose than after repeated daily dosing, and product information notes that some people have no symptoms, but no source reviewed gives a dose below which no action is needed. Toxicity can appear days later. Product information describes calcium folinate (folinic acid) as the specific antidote and says it should be started within one hour of the methotrexate, so its benefit falls with delay, and she is already several hours after the first dose. The MHRA and the BNF advise prompt medical attention when overdose is suspected. Blood tests and any antidote are decided by hospital or poisons specialists, which is why the decision should not wait for symptoms, even though she feels nearly well. Her normal kidney function (eGFR 82) is reassuring, and also something the hospital needs to know.
●Do not advise her to make herself sick. Do not advise extra folic acid as a replacement for assessment. Folic acid is not the antidote.

The First Minutes: What to Ask

●Confirm identity before disclosing, then check she is free and private.
●Establish the label wording, the number of tablets, the times and why the second dose was taken. She took four at breakfast and four again at lunchtime because she could not remember whether she had taken the first. Nothing since, and no folic acid today.
●Screen for nausea, vomiting, diarrhoea, mouth ulcers, sore throat, fever, bruising, bleeding, rash, cough and breathlessness. She has only mild nausea.
●Ask about other medicines that raise methotrexate levels. She took ibuprofen last night. NSAIDs should be avoided now. Ask about alcohol, antibiotics (trimethoprim and co trimoxazole especially), kidney and liver disease. Her recent bloods are in the brief and should be passed on.
●Establish that there is an old weekly box and a new box, so both can be put away and brought. Establish that she is alone, who can take her and how soon.
●Explore ideas, concerns and expectations: she assumed a dose increase, fears it is her fault, fears for her life and for her arthritis, and wants an honest account.

Duty of Candour: Disclosure and Apology

●The joint GMC and NMC guidance, Openness and honesty when things go wrong (updated December 2024), applies when something goes wrong and the patient suffers harm or distress, or may yet do so. After doing what you can to put matters right, you speak to the patient as soon as possible, share what you know and believe about what went wrong and the likely consequences, say what is still uncertain, answer questions honestly and apologise. You do not have to wait for an investigation. The guidance says patients expect an apology to cover what happened, what can be done about any harm, and what will be done to stop it happening to someone else. The organisational statutory duty of candour (Regulation 20, CQC) applies to notifiable safety incidents involving moderate or greater harm, and has a statutory requirement for a verbal and written notification. Even where the statutory threshold is not met, the professional duty applies.
●Do it by telephone, promptly, in your own name. Prepare her, then be direct: the prescription was written as daily and it should have been weekly. Say sorry and mean it. Do not blame the pharmacy, the computer system or her. Say what you know, what you do not know and what happens next.
●The same guidance says an apology is not an admission of legal liability, and that NHS Resolution will not refuse cover on a claim because an apology was given.
●She will ask how it happened and whether you will be in trouble. Answer honestly: the mistake was yours, it will be reported and reviewed, and you want to understand and prevent it. Avoid long defensive explanations.

Making It Safe: Prescription, Pharmacy and Rheumatology

●Correct the prescription and the repeat template so that it reads once weekly with a named day, as the MHRA advises (the day of the week is noted in full on the prescription). Contact the pharmacy, confirm what was dispensed, retrieve or replace the wrong box and thank the pharmacist for catching it.
●Tell the rheumatology team the same day. They decide when and how methotrexate is restarted and manage her arthritis in the meantime. She is likely to be without methotrexate for a short period. After the hospital assessment, any further monitoring bloods will be arranged by the hospital or shared care team.
●If she comes to harm, report the error to the MHRA through Yellow Card. The MHRA states that medication errors that result in patient harm should be reported this way. If no harm results, record it through the incident system.

Recording and Reporting: Significant Event and LFPSE

●Record the event on the practice significant event system and on the Learn from Patient Safety Events (LFPSE) service, the national NHS system that replaced the old national reporting system. The BNF lists overdose of methotrexate for non cancer treatment as an NHS Never Event category. Tell the practice manager or senior partner, and inform your indemnifier or defence body.
●The NHS England Patient Safety Incident Response Framework (PSIRF) emphasises learning, involving the patient and a proportionate response.
●A good review asks how this happened: free text dose and frequency, a repeat template changed without the weekly day recorded, no alert or prompt at issue, time pressure. Consider whether any other patients on methotrexate under your care have a similar risk and what will change.
●Document the call factually and at the time: what you said, what she said, timings, advice and who you contacted.

Follow Up and Safety Netting

●Phone her later today to check she arrived and again after discharge. Agree how and when she will hear about the review. Offer information on how to raise a concern or complain, without defensiveness.
●Specific safety netting for the next weeks: mouth ulcers, sore throat, fever or infection, bruising or bleeding, persistent vomiting or diarrhoea, a new cough or breathlessness, a rash. Give a named number and say what to do out of hours.

Common Mistakes in This Station

●Not confirming identity before disclosing.
●A passive or hedged apology, or none. Blaming the pharmacy, the system or the patient.
●Not asking how many tablets were taken, or missing the second dose.
●Advising her to wait at home and watch for symptoms, or offering only a routine appointment, with no same day specialist advice or assessment.
●Telling her to make herself sick, or to take folic acid instead of being assessed.
●Missing the ibuprofen or other interacting factors.
●Failing to ask about the old box, so a second supply stays within reach.
●Handing her over with no clinical handover or specialist advice.
●Restarting methotrexate without rheumatology.
●No plan to report, record, follow up and learn.

Mapped to the RCGP curriculum topic: Continuity and Quality of Care, Safety and Prescribing.

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